Barriers to the detection and management of depression by palliative care professional carers among their patients : perspectives from professional carers and patients' family members

Introduction: Clinical depression is highly prevalent yet underdetected and poorly managed within palliative care settings.

Objectives: This qualitative study explored the identification, monitoring, and management of symptoms of depression in patients receiving palliative care from 2 juxtaposed perspectives that are of care providers and care recipients' family members. Examining the barriers that restrict professional carers detecting and managing depression in their patients was a central focus of the study.

Methods: Focus groups were held with 18 professional carers, including 8 holding managerial positions, across 2 palliative care services, 1 regional and 1 metropolitan, which provided both inpatient and community-based care. Individual interviews were conducted with 10 family members of patients who had received or were receiving palliative care through these services.

Results: Thematic analysis of these data identified that both professional carers and family members perceived that depression is a wide-spread concern for patients receiving palliative care; however, numerous barriers were identified that affect professional carers’ ability to identify depression. These included knowledge and training deficits, low self-efficacy, prioritization of physical concerns and time constraints, patient/family characteristics, and system/process issues. These themes (and related subthemes) are discussed in this article.

Conclusions: Specialized training in depression is recommended for professional carers in order to improve their depression-related knowledge, detection skills, and self-efficacy. The ultimate goal of such training is to increase the rate of recognition of depression that in turn will lead to appropriate treatment for depressed patients.

"Lose 30lbs in 30 days" : assigning responsibility for deceptive advertising of weight-loss products

Purpose – The aim of this paper is to outline key social marketing issues apparent in deceptive weight-loss advertising, from the perspective of government policy-makers, manufacturers, the media, and consumers. The purpose is to examine the complexity of one aspect of the obesity battle and provide a framework for coordinated and integrated social marketing initiatives from a multiple stakeholder perspective.

Design/methodology/approach – The results of deceptive weight-loss advertising are framed using the harm chain model, and the paper offers recommended solutions based on a framework of marketing, education and policy changes across the network of stakeholders.

Findings – This paper concludes that a resolution to the harm created by deceptive weight-loss advertising can be achieved by the creation of a more holistic, system-wide solution to this important health and policy issue. This networked approach must involve all aspects of harm in a multi-stakeholder solution, including both upstream and downstream integration. Specific recommendations are made for policy-makers, manufacturers, the media, and consumers to achieve this goal.

Social implications – From a marketing perspective, analyzing the issue of deceptive weight-loss advertising using the harm chain allows for the creation of a more holistic, system-wide solution involving stakeholders in all aspects of harm for this important health and policy issue.

Originality/value – This research examines the problem of obesity and weight-loss advertising from the unique perspective of the harm chain framework. The authors make unified recommendations for various stakeholders including industry, media, government and consumers, in order to direct integrated social marketing and consumer-oriented strategies within this industry.

Mohair research update 18 : the importance of the live weight of Angora goats on husbandry and production

The live weight of farm animals is strongly associated with production, profitability, management requirements and animal survival (Table 1). The mature live weight of farm animals and of goats is positively associated with their potential to grow rapidly. Live weight is directly related to the nutrient requirements of goats, irrespective of their productive state.

For Angora goats in particular, live weight is associated with mohair production and mohair fibre diameter, age at puberty, reproductive performance and ovulation rate, carcass attributes, meat production and sale value at the end of their productive life. Live weight also affects the timing of the eruption of incisor teeth.

Associations between psychological stress, eating, physical activity, sedentary behaviours and body weight among women: a longitudinal study

Background: 

The relationship between the incidence of medullated fibres in mohair and live weight over the lifetime of Angora goats

The presence of even a small amount of medullated fibre, in otherwise high quality mohair, may have a pronounced adverse effect on its value and end-use potential. However, there is considerable confusion about the effects, if any, of environmental variables and management upon the incidence of medullated fibres in mohair. This study examined how the incidence of medullated fibres (Med, % by number) is related to the fleece-free live weight (FFLwt) of Angora goats of different genetic origins over their lifetime, and how the relationship varies with other lifetime factors. Measurements were made over 11 shearing periods of 6 months, on a population of Angora goats representing the current range and diversity of genetic origins in Australia, including South African, Texan and interbred admixtures of these and Australian sources. Records of breed, sire, dam, date of birth, dam age, birth weight, birth parity, weaning weight, live weight, fleece growth and fleece quality were taken for castrated males (wethers) (n = 94 animals). A restricted maximum likelihood (REML) model was developed for log10(Med + 1), which allowed the observations of the same animal at different ages to be correlated in an unstructured manner. Med varied between 0.1% and 4.3%. The median average FFLwt during a shearing interval increased from 15 kg at 1 year old to 59 kg at 6 years old. Generally, within each shearing interval, Med increased with increasing average FFLwt. However, the size and shape of the relationship differed greatly between shearing ages. For example, at 3.5 years of age Med increased from about 1.1% at an average FFLwt of 26 kg to 2.6% at 50 kg, whilst at 5.0 years of age Med only changed from 1.4% at 32 kg to 1.6% at 56 kg. Goats with mixed genetic parentage showed an increase in Med at some shearings, particularly at younger ages. Variation in animal nutrition, as measured by live weight change during shearing periods, did not affect Med. The results supplement our earlier findings that mohair mean fibre diameter and clean mohair fleece weight, but not staple length, are greater in larger Angora goats. Live weight needs to be taken into account in genetic evaluation of the incidence of medullated fibres. We conclude that any advantage in handling fewer but larger Angora goats rather than more but smaller goats will come at the detriment of producing lower quality mohair, both in terms of increased Med and mean fibre diameter.

Sustainability analysis and resource management for wireless mesh networks with renewable energy supplies

 There is a growing interest in the use of renewable energy sources to power wireless networks in order to mitigate the detrimental effects of conventional energy production or to enable deployment in off-grid locations. However, renewable energy sources, such as solar and wind, are by nature unstable in their availability and capacity. The dynamics of energy supply hence impose new challenges for network planning and resource management. In this paper, the sustainable performance of a wireless mesh network powered by renewable energy sources is studied. To address the intermittently available capacity of the energy supply, adaptive resource management and admission control schemes are proposed. Specifically, the goal is to maximize the energy sustainability of the network, or equivalently, to minimize the failure probability that the mesh access points (APs) deplete their energy and go out of service due to the unreliable energy supply. To this end, the energy buffer of a mesh AP is modeled as a G/G/1(/N) queue with arbitrary patterns of energy charging and discharging. Diffusion approximation is applied to analyze the transient evolution of the queue length and the energy depletion duration. Based on the analysis, an adaptive resource management scheme is proposed to balance traffic loads across the mesh network according to the energy adequacy at different mesh APs. A distributed admission control strategy to guarantee high resource utilization and to improve energy sustainability is presented. By considering the first and second order statistics of the energy charging and discharging processes at each mesh AP, it is demonstrated that the proposed schemes outperform some existing state-of-the-art solutions.

Testing the feasibility of a mobile technology intervention promoting healthy gestational weight gain in pregnant women (txt4two) - study protocol for a randomised controlled trial.

BACKGROUND: Overweight, obesity and excess gestational weight gain (GWG) are associated with negative health outcomes for mother and child in pregnancy and across the life course. Interventions promoting GWG within guidelines report mixed results. Most are time and cost intensive, which limits scalability. Mobile technologies (mHealth) offer low cost, ready access and individually-tailored support. We aim to test the feasibility of an mHealth intervention promoting healthy nutrition, physical activity and GWG in women who begin pregnancy overweight or obese. METHODS/DESIGN: txt4two is a parallel randomised control trial pilot recruiting women with a singleton, live gestation between 10(+0) and 17(+6) weeks at the first hospital antenatal clinic visit. Inclusion criteria are pre-pregnancy BMI > 25 kg/m(2) and mobile phone ownership. One hundred consenting women will be randomised to intervention or control groups at a 1:1 ratio. All participants will receive standard antenatal care. In addition, the txt4two intervention will be delivered from baseline to 36 weeks gestation and consists of a tailored suite of theoretically-grounded, evidence-based intervention strategies focusing on healthy nutrition, physical activity and GWG. This includes: mobile phone interactive text messages promoting positive health behaviours, goal setting and self-monitoring; video messages; an information website; and a private moderated Facebook® chat forum. The primary outcome is the feasibility of the intervention. Secondary outcomes include GWG and participants' knowledge and behaviour regarding diet and physical activity during pregnancy. DISCUSSION: Findings will inform the development of larger-scale mHealth programmes to improve the delivery of healthy pregnancy nutrition, physical activity and GWG, that could be widely translated and disseminated. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRNU111111544397 . Date of registration: 19 March 2014.

Problematic eating and food-related behaviours and excessive weight gain : why children in out-of-home care are at risk

Emerging evidence suggests that abuse and neglect in childhood may play a role in subsequent development of obesity. One population group particularly at risk is children and young people living in out-of-home care (OOHC). Given this population is already a vulnerable group, identifying potential mechanisms by which childhood abuse and neglect increases risk for obesity is essential. A possible explanation is that problematic eating and food-related behaviours (i.e., emotional eating, compulsive eating, overeating, binge eating, stealing or hoarding food) might mediate the association between adverse childhood experiences and obesity. Hence, the overall goal of this paper was to provide a narrative review of eating and food-related difficulties for children in care and their possible association with unhealthy and excessive weight gain. This review revealed a shortage of existing empirical papers and signalled particular need for further examination of the mediating effects of problematic eating.

Predictors of increased body weight and waist circumference for middle-aged adults

OBJECTIVE: To identify predictors of increased adiposity for different measures of adiposity. DESIGN: Prospective cohort study, the Melbourne Collaborative Cohort Study (MCCS), with data at baseline (1990-1994) and wave 2 (2003-2007). SETTING: Participants recruited from the community. SUBJECTS: Australian-born participants (n 5879) aged 40 to 69 years who were not current smokers and who were free from common chronic diseases at recruitment. At baseline and at wave 2, weight and waist circumference were measured; while demographic and lifestyle variables were obtained at baseline via structured interviews. RESULTS: Participants who reported any recreational physical activity at baseline had lower weight and smaller waist circumference at wave 2 than those who did not, particularly for younger participants and for vigorous physical activity. Walking for leisure was not associated, and greater physical activity at work was associated, with greater adiposity measures at wave 2. A diet low in carbohydrates and fibre, but high in fat and protein, predicted greater weight and waist circumference at wave 2. Participants were less likely to have elevated weight or waist circumference at wave 2 if they consumed low to moderate amounts of alcohol. CONCLUSIONS: Our findings indicate that promoting vigorous physical activity, encouraging a diet high in carbohydrate and fibre but low in fat and protein, and limiting alcohol intake could be promising approaches for preventing obesity in middle-aged adults. Similar interventions should successfully address the management of both weight and waist circumference, as they were predicted by similar factors.

Psychological health and lifestyle management preconception and in pregnancy

Healthful lifestyles before and during pregnancy are important to facilitate healthy outcomes for mother and baby. For example, behaviors such as a sedentary lifestyle and consuming an energy-dense/nutrient-poor diet increase the risk of overweight/obesity before pregnancy and excessive weight gain during pregnancy, leading to adverse maternal and child health outcomes. Maternal psychopathology may be implicated in the development of suboptimal maternal lifestyle behaviors before and during pregnancy, perhaps through impacts on motivation. This article explores this notion using maternal obesity and excessive gestational weight gain as examples of the health impacts of psychological states. We suggest that factors such as psychological well-being, individual motivation for behavior change, and broader environmental influences that affect both individual and system-wide determinants all play important roles in promoting healthy lifestyles periconception and are key modifiable aspects for intervention designers to consider when trying to improve dietary behaviors and increase physical activity before and during pregnancy. In addition, implementing system-wide changes that impact positively on individual and environmental barriers to behavior change that are sustainable, measureable, and effective is required.

End of life management of adult patients in an Australian metropolitan intensive care unit : a retrospective observational study

Background Death in the intensive care unit is often predictable. End of life management is often discussed and initiated when futility of care appears evident. Respect for patients wishes, dignity in death, and family involvement in the decision-making process is optimal. This goal may often be elusive. Purpose Our purpose was to review the end of life processes and family involvement within our Unit. Methods We conducted a chart audit of all deaths in our 10 bed Unit over a 12-month period, reviewing patient demographics, diagnosis on admission, patient acuity, expectation of death and not-for-resuscitation status. Discussions with the family, treatments withheld and withdrawn and extubation practices were documented. The presence of family or next-of-kin at the time of death, the time to death after withdrawal of therapy and family concerns were recorded. Results There were 70 patients with a mean age of 69 years. Death was expected in 60 patients (86%) and not-for-resuscitation was documented in 58 cases (85%). Family discussions were held in 63 cases (90%) and treatment was withdrawn in 34 deaths (49%). After withdrawal of therapies, 31 patients (44%) died within 6 h. Ventilatory support was withdrawn in 24 cases (36%). Family members were present at the time of death in 46 cases (66%). Family concerns were documented about the end of life care in only 1 case (1.4%). Conclusion Our data suggests that death in our Unit was often predictable and that end of life management was a consultative process.

A unified mixed-integer programming model for simultaneous fluence weight and aperture optimization in VMAT, tomotherapy, and cyberknife

All rights reserved. In this paper, we propose and study a unified mixed-integer programming model that simultaneously optimizes fluence weights and multi-leaf collimator (MLC) apertures in the treatment planning optimization of VMAT, Tomotherapy, and CyberKnife. The contribution of our model is threefold: (i) Our model optimizes the fluence and MLC apertures simultaneously for a given set of control points. (ii) Our model can incorporate all volume limits or dose upper bounds for organs at risk (OAR) and dose lower bound limits for planning target volumes (PTV) as hard constraints, but it can also relax either of these constraint sets in a Lagrangian fashion and keep the other set as hard constraints. (iii) For faster solutions, we propose several heuristic methods based on the MIP model, as well as a meta-heuristic approach. The meta-heuristic is very efficient in practice, being able to generate dose- and machinery-feasible solutions for problem instances of clinical scale, e.g., obtaining feasible treatment plans to cases with 180 control points, 6750 sample voxels and 18,000 beamlets in 470 seconds, or cases with 72 control points, 8000 sample voxels and 28,800 beamlets in 352 seconds. With discretization and down-sampling of voxels, our method is capable of tackling a treatment field of 8000-64,000cm3, depending on the ratio of critical structure versus unspecified tissues.

A cluster randomised controlled trial of vascular risk factor management in general practice

Objective: To evaluate the impact of a lifestyle intervention in Australian general practice to reduce the risk of vascular disease.

Design, setting and participants: Stratified cluster randomised controlled trial among 30 general practices in New South Wales from July 2008 to January 2010. Patients aged 40–64 years were invited to participate. The subgroup who were 40–55 years of age were included only if they had either hypertension or dyslipidaemia.

Intervention: A general practice-based health-check with brief lifestyle counselling and referral of high-risk patients to a program consisting of one to two individual visits with an exercise physiologist or dietitian, and six group sessions.

Main outcome measures: Outcomes at baseline, 6 and 12 months included the behavioural and physiological risk factors for vascular disease — self-reported diet and physical activity, and measured weight, body mass index, waist circumference, blood lipid and blood sugar levels, and blood pressure.

Results: Of the 3128 patients who were invited, 958 patients (30.6%) responded and 814 were eligible to participate. Of these, 699 commenced the study, and 655 remained in the study at 12 months. Physical activity levels increased to a greater extent in the intervention group than the control group at 6 and 12 months (P = 0.005). There were no other changes in behavioural or physiological outcomes or in estimated absolute risk of cardiovascular disease at 12 months. Of the 384 enrolled in the intervention group, 117 patients (30.5%) attended the minimum number of group program sessions and lost more weight (mean weight loss, 1.06 kg) than those who did not attend the minimum number of sessions (mean weight gain, 0.73 kg).

Conclusion: While patients who received counselling by their general practitioner increased self-reported physical activity, only those who attended the group sessions sustained an improvement in weight. However, more research is needed to determine whether group programs offer significant benefits over individual counselling in general practice.

Chronic disease self-management in Aboriginal communities : towards a sustainable program of care in rural communities

The Chronic Disease Self-Management (CDSM) strategy for Aboriginal patients on Eyre Peninsula, South Australia, was designed to develop and trial new program tools and processes for goal setting, behaviour change and self-management for Aboriginal people with diabetes. The project was established as a one-year demonstration project to test and trial a range of CDSM processes and procedures within Aboriginal communities and not as a formal research project. Over a one-year period, 60 Aboriginal people with type-2 diabetes in two remote regional centres participated in the pilot program. This represents around 25% of the known Aboriginal diabetic population in these sites. The project included training for four Aboriginal Health Workers in goal setting and self-management strategies in preparation for them to run the program. Patients completed a Diabetes Assessment Tool, a Quality of Life Questionnaire (SF12), the Work and Social Adjustment Scale (WASAS) at 0, 6 and 12 months. The evaluation tools were assessed and revised by consumers and health professionals during the trial to determine the most functional and acceptable processes for Aboriginal patients. Some limited biomedical data were also recorded although this was not the principal purpose of the project. Initial results from the COAG coordinated care trial in Eyre suggest that goal setting and monitoring processes, when modified to be culturally inclusive of Aboriginal people, can be effective strategies for improving self-management skills and health-related behaviours of patients with chronic illness. The CDSM pilot study in Aboriginal communities has led to further refinement of the tools and processes used in chronic illness self-management programs for Aboriginal people and to greater acceptance of these processes in the communities involved. Participation in a diabetes self-management program run by Aboriginal Health Workers assists patients to identify and understand their health problems and develop condition management goals and patient-centred solutions that can lead to improved health and wellbeing for participants. While the development of self-management tools and strategies led to some early indications of improvements in patient participation and resultant health outcomes, the pilot program and the refinement of new assessment tools used to assist this process has been the significant outcome of the project. The CDSM process described here is a valuable strategy for educating and supporting people with chronic conditions and in gaining their participation in programs designed to improve the way they manage their illness. Such work, and the subsequent health outcome research planned for rural regions, will contribute to the development of more comprehensive CDSM programs for Aboriginal communities generally.

Implementing the Flinders Model of self-management support with Aboriginal people who have diabetes : findings from a pilot study

A pilot program for Aboriginal people with diabetes on Eyre Peninsula, South Australia, aimed to test the acceptability and impact of using the Flinders model of self-management care planing to improve patient self-management. A community development approach was used to conduct a twelve-month demonstration project. Aboriginal health workers (AHWs) conducted patient-centred, self-management assessment and care planning. Impacts were measured by patient-completed diabetes self-management assessment tool, goal achievement, quality of life and clinical measures at baseline and 12 months. Impact and acceptability were also assessed by semi-structured interviews and focus groups of AHWs. Sixty Aboriginal people with type 2 diabetes stated their main problems as family and social dysfunction, access to services, nutrition and exercise. Problems improved by 12% and goals by 26%, while quality of life scores showed no significant change. Self-management scores improved in five of six domains. Mean HbA1c reduced from 8.74-8.09 and mean blood pressure was unchanged. AHWs found the process acceptable and appropriate for them and their patients. It was concluded that a diabetes self-management program provided by AHWs is acceptable, improves self-management and is seen to be useful by Aboriginal communities. Barriers include lack of preventative health services, social problems and time pressure on staff. Enablers include community concern regarding the prevalence and mortality associated with diabetes.